AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis

Abstract

There are approximately 800,000 hospitalizations a year for cirrhosis complications in the United States, and 7%-8% of these patients require intensive care at an estimated cost of $2 billion [1] but without standardized intensive care protocols. Acute-on-chronic liver failure (ACLF) is a term often applied to patients with chronic liver disease with or without cirrhosis with hepatic and extrahepatic organ failures, most of whom require intensive care. This document from the American Association for the Study of Liver Diseases (AASLD) serves to provide guidance and a data-supported approach for the diagnosis, evaluation, and management of patients with cirrhosis and ACLF as well as cirrhosis and critical illness. It differs from the AASLD Guidelines, which are supported by systematic reviews of the literature, formal rating of the quality of the evidence, and strength of the recommendations. In contrast, this document was developed by consensus of an expert panel and provides guidance statements based on a comprehensive review and analysis of the literature on relevant topics with oversight provided by the AASLD Practice Guidelines Committee. The AASLD Practice Guidelines Committee chose to perform a guidance on this topic because there are an insufficient number of randomized controlled trials (RCTs) available to support meaningful systematic reviews and meta-analyses.

Higher Rate of SBP Recurrence with Secondary SBP Prophylaxis Compared to No Prophylaxis in Two National Cirrhosis Cohorts

“…With advancing cirrhosis and development of ascites, there is a risk of spontaneous bacterial peritonitis (SBP) [1]. Delays in or absence of SBP treatment is associated with acute kidney injury, organ failure(s), acute-on-chronic liver failure and death, and once SBP occurs, there is a high rate of recurrence [2,3,4]. The microbiome in patients with cirrhosis changes as liver disease progresses, with etiology of liver disease, and with medications given.…”

The SILK Collaborative: A Multidisciplinary Approach to Serious Illness Communication for Patients with Liver Failure and AKI

“…5 However, transplant decision making in the setting of ACLF is complex and evolving-many patients who had previously been deemed transplant ineligible because of critical illness are now being offered the hope of liver transplantation. 1 Initiation of RRT in these circumstances may support patients who are undergoing urgent inpatient transplant evaluation to determine their transplant candidacy. Furthermore, given rising rates of alcohol-associated hepatitis in young adults, some hepatologists may recommend trials of dialysis even among the transplant-ineligible.…”

“…To introduce our SILK collaborative, we led joint Mass General Brigham gastroenterology-nephrology grand rounds in April 2023 titled "A Team-Based Approach to Patients with HRS" that had over 100 multidisciplinary attendees. Our objectives were as follows: (1) to provide an overview on the management of HRS and its treatment, including use of terlipressin; (2) to describe key roles and best practices for collaboration among nephrology, hepatology, critical care, and palliative care; and (3) to introduce serious illness conversations in the context of ACLF and AKI. We presented a case of a 36-year-old man with alcohol-related cirrhosis who presented with ACLF and AKI.…”

“…Acute-on-chronic liver failure (ACLF) is a morbid diagnosis describing the development of extrahepatic organ failures among hospitalized patients with cirrhosis that carries high risk of short-term mortality. 1 AKI is a common presentation of ACLF and occurs in up to 50% of hospitalized patients with cirrhosis. 2 When patients with ACLF develop AKI, the most common etiologies are acute tubular injury (ATN) and hepatorenal syndrome (HRS).…”